Contraception Flashcards
What is important to ascertain when considering contraception
What kind do they need: barrier, long-term, emergency
Is the purpose to prevent pregnancy or STIs
Are they happy to regularly take a pill / will they be able to remember
PMH Migraine with aura
FHx oestrogen-dependant cancers (endometrial, breast, ovarian)
What are the types of barrier contraception and what are their advantages and disadvantages
Condom: (-) least effective contraception
Female condom: (-) has to be held in positions
Cervical diaphragm: (+) has spermicidal gel (-) requires planning for insertion and after intercourse (±2 hours)
Caya (diaphragm): popular in post natal women
Only form of contraception to also protect against STIs
What are the types of long acting reversible contraception (LARC)
Copper IUD
Hormone coil (IUS)
Implant
Depot
Jaydess
Kyleena
How does the copper coil work and what are the contraindications
Aseptic inflammation → decreases sperm motility, survival, and ability to implant
Contraindications to IUDs/IUS = pregnancy, PID, malignancy, unknown bleeding
How and when is the copper coil administered
Inserted:
- Coil on stem only: 5 years
- Coil on stem + T arms: 10 years
Immediate contraceptive ability, inserted at any point in cycle
After childbirth, insert: <48 hours OR after 4 weeks
What are the disadvantages of the copper coil
Longer, more painful periods:
Heavier periods (not recommended for menorrhagia)
Dysmenorrhoea
Uterine perforation (2 per 1000 insertion)
Pelvic inflammatory disease (first 20 days)
1 in 20 risk of expulsion (first 3 months)
How does the hormone coil work
Releases progesterone → thins the lining of the endometrium → induces lighter periods or even amenorrhoea
- Beneficial to anaemic patients and those with uterine bleeding concerns e.g. fibroids
- Prevents un-opposed oestrogen and therefore endometrial hyperplasia
- Beneficial for STI prevention due to cervical mucous thickening → mucous plug
How and when is the hormone coil inserted and what are the contraindications
Inserted and left for 3-5 years
Additional contraception is needed for 7 days after insertion (unless <5 days of a new cycle)
CI: pregnancy, PID, malignancy, unknown bleeding (must do STI screen prior)
What are the disadvantages of the hormone coil
Irregular bleeding (but followed by lighter menses/amenorrhoea)
Acne
Constipation
Irritability
Breast tenderness
Mood changes
Headache
Coil expulsion
Infection
Perforation
What is Jaydess and Kyleena
Jaydess = mirena-like alternative but effective for only 3 years, thinner, easier insertion, preferable in nulliparous women
Kyleena = Smaller IUS, effective for 5 years, associated with weight gain
What is the MOA for the implant
Releases progesterone (etonogestrel)
Prevents ovulation and thickens the cervical mucous
How and when is the implant administered
Small rod inserted sub-dermally into non-dominant arm with local anaesthetic
Lasts for 3 years
Additional contraception is needed for 7 days after insertion (unless <5 days of a new cycle)
What are the disadvantages of the implant
GI: constipation
Irregular bleeding
irritability and mood changes
Breast tenderness
Headache
Implant site infection
Acne
How does Depo-provera work
Progesterone (medroxyprogesterone acetate)
Prevents ovulation, thickens cervical mucous
How and when is depo-provera administered
IM
Lasts 12-14 weeks (4 months)
Needs at least 7 days to be effective - use barrier in this time
What are the disadvantages of depo-provera
Weight gain
Ectopic pregnancy
Takes 6-12 months for fertility to return from last injection
Osteoporosis (should be avoided in extreme reproductive age e.g. 13, teens, women in their 40s)
GI: constipation
Irregular bleeding
irritability and mood changes
Breast tenderness
Headache
Acne
What are the types of user-dependent contraception
Combined oral contraceptive pill/patch/vaginal ring
Progesterone only pill
What is the MOA for the COCP
Oestrogen (ethinyl oestradiol) and progesterone (progestin) that prevents ovulation
How and when should combined oral contraception be taken
Day 1 (up to day 5) of the menstrual cycle is the preferred day to start (immediate protection from pregnancy)
- If there is a need for extra barrier contraception, this should be used for at least 7 days
Forms:
Pills (e.g. microgynon): 1 pill daily for 3 weeks followed by a week of no pill for withdrawal bleed OR 1 pill daily for 9 weeks followed by 1 week off
Patches: 1 patch a week for 3 weeks followed by no patch for a week for withdrawal bleed
Vaginal ring: 1 ring for 3 weeks, then take out for one week)
What are the benefits of using the COCP
> 99% effective
Reversible on stopping
Less pain, more regular, lighter periods
Reduced risk of ovarian, endometrial, bowel cancer
What are the disadvantages of the COCP
Easy to forget to take
Does not protect against STIs
Increased risk of VTE (stoke, heart disease)
Increased risk of breast and cervical cancer
Side effects: headache, N&V, breast tenderness
What are the contraindications for the COCP
UKMEC 4:
Migraine with aura
<6w postpartum and breastfeeding
Ischaemic of valvular HD
Diabetes with complications
>35yo, smoke >15/day
PMHx VTE, TIA, stroke
Severe cirrhosis or liver tumour
BP >160/100
Current breast cancer
What are the considerations for the COCP around surgery
Needs to be discontinued at least 4 weeks prior to surgery
Re-start 2 weeks after full mobilisation
What should be done if the patient misses a dose of the COCP
1 pill missed: take last pill and current pill (even if 2 in 1 day) → no further action needed
2 pills missed: take last pill and current pill (even if 2 in 1 day) AND:
- Use condoms until pill has been taken correctly for 7 days in a row
- 2 Missed in Week 1: consider emergency contraception
- 2 Missed in Week 2: no need for emergency contraception o
- Missed in Week 3: finish current pack, start new pack immediately (no pill-free break)
What is the MOA for the progesterone only pill
Progesterone (progestin): levonorgestrel, norethisterone, desogestrel (cerazette)
Thickens the cervical mucous (desogestrel stops ovulation)
How and when should the progesterone only pill be taken
OD at the same time every day (no pill-free week)
If started on the first 5 days of the cycle (28-day cycle) → confers immediate contraceptive protection
If starting at any other time, use additional measures for the first 2 days
If switching over from the COCP, it provides immediate protection
What are the disadvantages of the progesterone only pill
Easy to forget to take
Initial irregular bleeding → continued, regular bleeding, amenorrhoea
Osteoporosis and ovarian cyst
SEs: irregular bleeding, acne, constipation, irritability, breast tenderness, mood changes, headache
What should be done if a patient misses their dose of progesterone only pill
Traditional (micronor, noriday, nogeston, femulen)
- <3hours: continue as normal
- >3 hours: take the missed pill ASAP and continue with the pack, use condoms until pill taking has been re-established for 48 hours
Cerazette (desogestrel)
- <12h: continue as normal
- >12h: take missed pill ASAP, continue with rest of pack, condoms until re-establishment for 48h
What should be done if a patient forgets to change their combine hormonal transdermal patch
Delayed change <48 hours: change immediately with no further precautions
Delayed change >48 hours (week 1 or 2): change immediately, use barrier protection for 7 days
- If UPSI <5 days or during extended patch-free period, consider emergency contraception
Delayed removal >48 hours (week 3): remove immediately and apply next patch on the usual start date of the next cycle (no additional contraception is needed)
Delayed at the end of the patch-free week: use barrier contraception for 7 day
Where may someone acquire emergency contraception
Pharmacies, sexual health clinics, GP centres, A&E, some schools
£24.99, but free for under 16s
What are the options for emergency contraception
Levonorgesterol (Levonelle)
Copper coil (IUD)
Ulipristal acetate (ellaOne)
What is the MOA for Levonorgesterol (Levonelle) and when is it effective
High dose progesterone - stops ovulation and inhibits implantation
taken within 3 days (72h) of UPSI
95% effective in <24 hours
84% effective <72 hours
What is the MOA for Ulipristal acetate (ellaOne)
Selective progesterone receptor modulator → inhibits ovulation
Use within 5 days
95% effective in <120 hours (5 days)
First line if BMI >26
What is the MOA of the copper IUD as emergency contraception
Most effective form of contraception
Spermicidal and inhibits implantation
>99% effective in <120 hours
Use within 5 days of UPSI
What is the Pearl index
describes the chance of becoming pregnant on contraception
Pearl index = the number of pregnancies occurring per 100 woman-years
When can women stop using barrier contraception for UPSI
<50: after 2 years of amenorrhoea
>50: after 1 year of amenorrhoea
When can women stop using the COCP for UPSI
Continue and stop after 50yo, switch to a non-hormonal or the POP
When can women stop using progesterone contraceptive forms for UPSI
Can continue beyond 50 years
Depo-provera: stop at 50yo and switch to a non-hormonal/POP
What should be done if a patient vomits after taking emergency contraception
if vomiting occurs within 3 hours then the dose should be repeated
When can hormonal contraception be started after taking emergency contraception
levornogestrel (Levonelle): immediately
Ulipristal(EllaOne): Contraception with the pill, patch or ring should be started, or restarted, 5 days after. Barrier methods should be used during this period
